Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program (2016)

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3 Treatment and Persistence of Speech and Language Disorders in Children This chapter addresses three topics within the committee’s charge: cur- rent standards of care for speech and language disorders in children; which of the disorders are amenable to treatment and the typical time course re- quired for this treatment; and the persistence of these disorders in children. The discussion is limited to those childhood speech and language disorders that are most common in the Supplemental Security Income (SSI) popula- tion; it is not intended to be a comprehensive review of interventions for or the persistence of speech and language disorders. The chapter begins with an overview of the factors that influence treatment of speech and language disorders in children. This is followed by a summary of policies and guide- lines that influence the provision of treatment services. Next is an age-based description of treatment approaches. The chapter ends with discussion of the persistence of childhood speech and language disorders and the com- mittee’s findings and conclusions. Before beginning it is important to emphasize that treatment is con- sidered to be essential for all children with speech and language disorders, but with few exceptions, it is most effective for less severe disorders. Nevertheless, even children with the most severe disorders can develop en- hanced, functionally important communication skills that have a meaning- ful impact on their lives even though their speech and language disorders have not been completely resolved. 81 

82 SPEECH AND LANGUAGE DISORDERS IN CHILDREN FACTORS THAT INFLUENCE TREATMENT FOR SPEECH AND LANGUAGE DISORDERS Speech and language treatment programs employ a variety of ap- proaches that are dependent on the particular needs and circumstances of the child. Several important factors shape the appropriate intervention pro- gram for any given child. These include treatment objectives based on the severity of the disorder, the developmental level of the child, the individuals involved in the intervention (or “agents of change”), the setting in which treatment is provided, and certain key properties of speech and language. Each of these factors is described in turn below. Objectives of Treatment Based on the Severity of the Disorder For children with severe speech and language disorders, it often is not possible to alter underlying limitations in developmental processes and systems, partly because of the current state of knowledge in developmental and learning sciences. For some children, conventional means of commu- nication are impossible given the child’s level of development and sever- ity of communication difficulties. In these cases, compensatory means of communication, such as picture cards or computer-based communication systems, are employed. Furthermore, parents of children with severe speech and language disorders often are in need of support as well (Zebrowski and Schum, 1993). Developmental Level of the Child Treatment programs must be adapted to the child’s current develop- mental status with respect to both speech and language skills and general social, emotional, and physical development. Treatment programs are, therefore, designed to build on the child’s developmental level, regardless of the child’s age (Brown and Ferrara, 1999). Thus, for example, a 5-year-old child who is functioning at a 3-year-old level in language is unlikely to be able to acquire the language skills of a typical 5-year-old without having ac- cumulated the intermediary skills normally acquired between ages 3 and 5. Agent(s) of Change Treatment programs for speech and language disorders nearly always require that someone, usually an adult, provide an environmental milieu that promotes speech and language growth (Paul and Norbury, 2012). Some computer-based programs that require a minimum of adult interac- tion have been developed (Tallal et al., 1996), but there is no consensus on 

TREATMENT AND PERSISTENCE 83 their effectiveness (Cohen et al., 2005; Gillam et al., 2008; Strong et al., 2011). Thus, speech and language therapy usually requires that the child be engaged with a partner (clinician, parent, peer) who is a competent speaker/ listener of the language. This engagement becomes the means of producing learning and behavior change. Various types of individuals can be consid- ered agents of change for and integral to speech and language treatment for children, including professionally trained and certified speech-language pathologists, parents, early childhood educators or teachers, and peers. In some cases, the role of the speech-language clinician may be as a consultant and educator for others who are the primary agents of change. Treatment Setting Treatment may occur in a number of settings or environments because speech and language skills develop within the context of a child’s daily communication activities—for example, at home, in the neighborhood, and in school. Each setting provides opportunities for communication and interaction. In the past, speech and language therapy was provided almost exclusively in therapy rooms and classrooms where the speech-language clinician engineered the environment to promote learning (McWilliam, 1995). In the past two decades, however, speech and language intervention has moved out of these special-purpose environments (Peña and Quinn, 2003). This practice is predicated in part on the belief that treating in these natural settings will promote generalization of learning to these settings. For children younger than 3 years of age, services may be provided in the home (Mahoney et al., 1999). Preschoolers may be served in an early child- hood or daycare setting, while treatment programs for school-age children usually are integrated into the classroom. Key Properties of Speech and Language Chapter 2 describes language as involving several interrelated systems used together to accomplish communication. Box 3-1 briefly defines these systems, explaining how they make it possible to understand the meaning and intent of utterances spoken by others and to use words and sentences to express meaning and intent to others. What is heard and what is said can be thought of as the superficial manifestations of communication. Underlying these manifestations are complex knowledge systems stored in memory systems in the brain. This complex combination of knowledge and skills that must be acquired by a child is the common target of speech and language therapy. 

84 SPEECH AND LANGUAGE DISORDERS IN CHILDREN BOX 3-1 Basic Systems and Subsystems That Enable Human Communication Phonology: the sounds of a language that distinguish one word from an- other (e.g., cat versus sat), as well as the allowable sequences of these sounds Vocabulary: sound combinations in a language that are associated with meaning Grammar: the principles in a language governing arrangements of words that convey propositional meaning (e.g., who does what to whom, when, why, and/or how) Pragmatics: principles that govern how the above systems are employed effectively and appropriately to accomplish the social functions of communication Speech and Language Knowledge Is Implicit The typical child develops speech and language knowledge quickly and with little conscious effort and, importantly, with little intentional instruction by his or her parents (Pinker, 1984). As an example, consider the following sentence: “The basketball player dribble ball.” Most native English-speaking adults would revise the sentence and automatically change “dribble ball” to “dribbles the ball.” Although these kinds of judgments of mature English speakers are common, many adults cannot explain why they make these judgments. This kind of knowledge is often called implicit knowledge—knowledge that is acquired through experience or exposure, rather than from explicit instruction—and much of a young child’s speech and language learning develops through this implicit process (Bock and Griffin, 2000; Conway et al., 2010). In this way, much of speech and lan- guage learning is akin to learning to tie a shoe or ride a bike—skills that can be acquired only by doing and, in fact, are difficult to explain without demonstrating. This type of learning requires repeated exposure or practice, and the resulting knowledge builds gradually. Speech and Language Knowledge Is Abstract The implicit knowledge that accumulates during speech and language development is abstract. Knowledge of grammar appears to require pro- cessing such notions as the subject of a sentence, which involves the role of a phrase in a sentence that governs certain grammatical features of the sentence. Words usually refer to classes of referents and phonemes (speech 

TREATMENT AND PERSISTENCE 85 sounds) that comprise categories of specific speech sounds (phones). These abstract relations, roles, and categories allow language to express mean- ings in consistent but flexible ways. How these abstractions are acquired is a topic of considerable debate (Bates and MacWhinney, 1987; Chomsky, 1986; St Clair et al., 2010). Although sentences involving such abstractions can be provided to a young child, the actual abstraction cannot; instead, the child must create it. Thus, the child can be given the raw material from which language is learned, but the abstract learning product must be generated through mental processes within the child. Unlike a physical therapist, who can physically change the state of a targeted tissue through manipulation, a speech-language clinician cannot make direct contact with these mental processes because they are dynamic learning processes within the brain. Knowledge Allows for Creativity Another important characteristic of speech and language knowledge is that it allows for considerable creativity and adaptability. A key feature of language is that what one says is often novel; that is, one can say things one has not heard before. This creative aspect of language can be used to adapt and adjust what one says to a particular situation. This adaptability also is seen in speech production and the ability to produce intelligible speech in a variety of ways. Thus, knowing a language is not simply imitating or stor- ing away a collection of words or sentences to be called up when needed, but using rules or principles and abstract knowledge in flexible and creative ways. As a result, although treatment may target and change relatively specific aspects of speech and language, the child’s ability to understand and produce novel utterances that are necessary for communication will be quite limited unless the treatment results in broader changes in underlying skills and knowledge. POLICIES AND GUIDELINES THAT INFLUENCE THE PROVISION OF SPEECH AND LANGUAGE SERVICES TO CHILDREN Numerous factors influence the range of treatments and services re- ceived by children with speech and language disorders. Within the universe of children with such disorders who receive SSI benefits, several sets of poli- cies might be expected to play an especially prominent role: the Individuals with Disabilities Education Act (IDEA); Medicaid and its special early and periodic screening, diagnosis, and treatment (EPSDT) benefit for children and adolescents up to age 21, to which all children receiving SSI are en- titled; and policies established by the leading professional society in the area 

86 SPEECH AND LANGUAGE DISORDERS IN CHILDREN of speech and language treatment, which guide the provision of treatment under public programs. Individuals with Disabilities Education Act IDEA1 requires that all children with disabilities—including speech and language disorders—be provided a free, appropriate public education in the least restrictive environment possible. Part B of this law applies this mandate to children aged 3-22, whereas Part C extends this mandate to children from birth to 3 years of age. Within the United States, speech and language services for children usually are provided by school systems as part of special education services (U.S. Bureau of Labor Statistics, 2014). However, speech and language ser- vices are not provided exclusively by public school systems; they also can be found in some community-based programs, such as Head Start. Payment for services both within and outside of the school system are covered by Medicaid. Children with speech and language disorders may also receive treatment and services through privately funded programs, such as those supported by Easter Seals or the Scottish Rite Language Clinics. Medicaid Early and Periodic Screening, Diagnosis, and Treatment Program Under the Medicaid EPSDT program, children under 21 who are en- rolled in Medicaid must be provided appropriate preventive and specialty services for audiology and speech and language disorders (CMS, n.d.). This includes “diagnostic, screening, preventive, or corrective services pro- vided by or under the direction of a speech and language pathologist or audiologist.”2 Specifically, the EPSDT benefit provides coverage for • the identification of children with speech or language impairments; • diagnosis and appraisal of specific speech or language impairments; • referral for medical or other professional attention necessary for rehabilitation of speech or language impairment; • provision of speech and language services; and • counseling and guidance of parents, children, and teachers (ASHA, n.d.). 1  Individuals with Disabilities Education Act of 2004, Public Law 108-446, 108th Cong. (December 3, 2004). 2  42 C.F.R. § 440.110(c). 

TREATMENT AND PERSISTENCE 87 American Speech-Language-Hearing Association Services for children with speech and language disorders are also in- fluenced by the American Speech-Language-Hearing Association (ASHA), which has issued practice guidelines for speech and language therapy: Children receive intervention and/or consultation services when their abil- ity to communicate effectively is impaired because of a communication disorder and when there is a reasonable expectation of benefit in body structure/function and/or activity/participation. Interventions that enhance activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited. (ASHA, 2004) With regard to the duration of treatment, ASHA states, Intervention extends long enough to accomplish stated objectives/predicted outcomes and ends when there is no expectation for further benefit during the current developmental stage. (ASHA, 2004) In many cases, the duration of treatment can be protracted, given that throughout childhood, the functional requirements for language and com- munication continually increase and often outpace the child’s growth (see Figure 3-1). Thus, a child with a speech and/or language disorder, although making progress, falls further behind his or her typically developing peers in the ability to meet functional communication expectations. As a result, and in keeping with the ASHA guidelines, treatment often is protracted, particularly for children with severe speech and language disorders. TREATMENT FOR SPEECH AND LANGUAGE DISORDERS The primary objective of treatment for speech and language disorders is to ameliorate a child’s communication difficulties and thereby reduce or minimize the negative sequelae associated with these disorders. Optimal treatments would be those that resolved or cured the problem and thus resolved the disability. Indeed, some treatments for speech and language disorders may approach this level of efficacy for some children. Two ex- amples are given here. First, children born with clefts of the lip and palate are at considerable risk for poor speech intelligibility. Advances in early surgical management of clefts of the lip and/or palate have resulted in substantial improvements in the speech outcomes of affected children, often permitting normal levels of speech development (Bzoch, 1997). Although surgery serves as an impor- tant treatment, surgery alone is not sufficient in the majority of instances to 

88 SPEECH AND LANGUAGE DISORDERS IN CHILDREN FIGURE 3-1  Persistence of the disparity between growth in functional communica- tion skills for typically developing children and for those with language disorders. fully resolve the risk for speech impairment, and behavioral treatment (i.e., speech therapy) often is needed as well (Hardin-Jones and Jones, 2005). Similarly, children who are born deaf or hard of hearing have very high rates of speech and language impairment. During the past several decades, auditory prostheses such as hearing aids and cochlear implants, when paired with appropriate and intensive interventions, have been shown to lead to considerable improvements in the speech and language outcomes of these children (Niparko et al., 2010; Tomblin et al., 2014b). Yet despite the effectiveness of these prostheses, the risk of poor speech and language outcomes remains for some children. Both surgery for cleft lip and palate and the provision of auditory pros- theses are interventions directed at the fundamental cause of the speech/ language disorder. Each reflects etiologies impacting peripheral systems for communication (anatomical structures for speech or sensory input) that are relatively amenable to direct intervention. For the vast majority of speech and language disorders, however, the cause is unknown or when known, involves developmental impairments of the brain (see Chapter 2). For these disorders, there currently are no interventions, such as a pharmacological 

TREATMENT AND PERSISTENCE 89 or surgical treatment, that can resolve the cause of the problem and thus result in substantial resolution of the child’s disability. Instead, the treat- ment of these pediatric speech and language disorders consists of behavioral approaches that improve function, and among more severely impaired chil- dren, treatment rarely results in resolution of the overall disability. Early Intervention (Birth to Age 3) for Language and Speech Sound Disorders Early Intervention Approaches The need for language intervention may be identified quite early in an infant’s life, particularly when the child has comorbid disabilities that are known to be consequential for speech and language development (e.g., Down syndrome, cerebral palsy, fragile X syndrome, autism spectrum dis- order, traumatic brain injury, being deaf or hard of hearing). In other cases, infants or young children fail to meet early language or speech milestones (e.g., development of meaningful speech, ability to produce or combine words by 24 months of age), which prompts enrollment in intervention. When children are quite young, language intervention typically is imple- mented through a family-centered approach. The intervention is carried out by the parents or caregivers, while the speech clinician takes on a support role, providing guidance that helps parents/caregivers develop the knowl- edge and skills needed to promote the child’s development throughout everyday routines and interactions. These approaches entail providing a context of emotional support for family members, who may be adjusting to the child’s developmental chal- lenges and the resulting impact on family life. In addition, family-centered practices recognize the influential role of caregivers and the home context in children’s development. For example, a skilled clinician may provide early intervention for 1-2 hours per week, which represents only a fraction of a young child’s nearly 100 hours weekly of awake and potential learning time (Warren et al., 2006). The intent of family-centered, parent-imple- mented approaches is to support the ability of caregivers to promote the child’s communicative development throughout everyday routines (Rush and Shelden, 2008). Very early research on talk to children (Brown and Bellugi, 1964) re- vealed that parents sometimes rephrase things children say. For example, when a child says, “See doggy,” the parent may follow by saying, “Yes, see the doggy.” This form of parent behavior was termed “expansion” in that the parent provided a model of a grammatically well-formed sentence by expanding the child’s utterance. A variant on expansion called “recasts” entails reformulation of a child’s prior well-formed utterance to include 

90 SPEECH AND LANGUAGE DISORDERS IN CHILDREN additional and more advanced grammatical properties (Nelson et al., 1973). Thus, the child might say, “The doggy is barking,” and the adult might fol- low by saying, “Yes, the doggy is barking very loudly, isn’t he?” In one early study, children exposed to increased rates of expansion and recasts showed improved grammatical development (Nelson et al., 1973). Subsequent re- search showed that children exposed to elevated rates of expansion have better language growth (Cleave et al., 2015; Leonard et al., 2004; Nelson et al., 1996). Other examples of caregiver use of talk that encourages language development include “parallel talk” (e.g., describing in the moment what the child is doing or experiencing, such as “You are swinging so high.”) and open-ended questions whose answers are unknown to the caregiver (e.g., “What else do you want?”) (Fey et al., 1999; Proctor-Williams et al., 2001; Szagun and Stumper, 2012). In addition to supporting parents in using responsive language, it is important to reduce the use of caregiver styles that are overly directive and/ or controlling of the child, such as leading the child’s attention away from current interests, correcting grammar (“Say it this way, not that way.”), or withholding an object until the child speaks. Maternal directiveness has been negatively associated with subsequent child language outcomes (Landry et al., 1997, 2000; Rowe, 2008), which has led interventionists to provide caregivers with feedback and support that promote responsive rather than directive interactions. Enhanced parental confidence is emphasized in interventions focused on caregiver promotion of language abilities throughout daily routines. Early interventionists seek to promote caregivers’ self-efficacy in their roles in promoting the child’s development, defined as the “expectations caregiv- ers hold about their ability to parent successfully” (Jones and Prinz, 2005, p. 342). Caregivers with low levels of self-efficacy may find it difficult to persist when presented with challenges in parenting their child. In contrast, high levels of maternal self-efficacy have been linked to responsiveness to the child and the provision of stimulating interactions (Coleman and Karraker, 2003). Indeed, promoting caregiver responsiveness to the child and to the child’s efforts to communicate is another primary goal of early intervention. This approach builds on decades of research showing that children exposed to conversational talk that is responsive have better rates of language devel- opment than those who are not (Cross, 1978; Goldfield, 1987; Landry et al., 2006; Tamis-LeMonda et al., 1996). One form of this responsive com- munication occurs when the parent or clinician says something that builds on the meaning of the child’s prior utterances—referred to as “semantic extensions” (Cleave et al., 2015). The effectiveness of semantic extensions in promoting language growth was first shown by Cazden (1965). 

TREATMENT AND PERSISTENCE 91 Interventions Focused on Promoting Language Growth in Young Children The section above focuses on early intervention aimed at support- ing caregivers in being responsive and employing qualitative features in their use of language that are known to promote children’s linguistic de- velopment. Within the early intervention context, numerous intervention approaches have been developed to promote the child’s growth along a developmental continuum. It is beyond the scope of this report to provide comprehensive coverage of the multiple goals, approaches, and techniques involved in child-focused interventions. However, commonly selected child targets in early language intervention and treatment goals for meeting those targets are summarized in Box 3-2. BOX 3-2 Selected Examples of Targets and Treatment Goals in Early Language Intervention (birth to age 3) Treatment Goals Prelinguistic •  ncrease prelinguistic behaviors that are foundational I communication  language development in preverbal children (Warren to et al., 2008; Yoder and Warren, 1998, 2002). − Increase child’s use of gestures −  ncrease use of eye gaze to signal desires, wants I −  romote shared attention and joint engagement P − Increase child’s use of vocalizations − Increase intentional communication attempts −  romote combining communication modes (gesture P + vocalization + eye gaze) Vocabulary • Promote child’s understanding and use of diverse development  ord types and concepts (e.g., object and person w names, verbs, descriptive terms) to strengthen language comprehension and promote word learning and use of word combinations (Girolametto et al., 1998; Lonigan and Whitehurst, 1998; Marulis and Neuman, 2010) Early word • Target grammatical forms that are emerging and combinations represent next developmental steps for t e child h and grammar  Fey et al., 2003); promote word combinations with ( increasing length and complexity (i.e., including word endings) once the child shows sufficient readiness (Hadley, 2014) continued 

92 SPEECH AND LANGUAGE DISORDERS IN CHILDREN BOX 3-2  Continued Pragmatics •  mphasize child’s ability to express a range of E communicative functions (e.g., request, protest, comment, question [Bates, 1976]) •  dults contingently responsive to child’s A communicative attempts (in a variety of forms) to promote child’s participation in conversational turn- taking interactions (Fey et al., 2006; Landry et al., 2001) Selected Intervention Strategies Enabling • Environment is modified in ways that result in environments  frequent exposure of child to developmentally appropriate language models and opportunities to use emerging language abilities (Finestack and Fey, 2013; Hemmeter and Kaiser, 1994; Warren et al., 2006) Joint • Caregivers learn to encourage child’s participation engagement in social routines by being responsive and focusing routines with on child’s interests (Girolametto et al., 1994; adult responsivity  asari et al., 2010; Yoder and Warren, 2001) K Focused • Clinician identifies specific language targets (e.g., stimulation  vocabulary, grammar, language functions), and adults provide multiple exposures to child’s targets and encourage child to produce the targets (Leonard, 1981) •  ay include elicitation strategies such as imitation M prompts (Camarata et al., 1994; Ingersoll and Lalonde, 2010; Kouri, 2005); emphasis may be placed on targeted forms (Robertson and Weismer, 1999) •  xplicit and implicit vocabulary instruction provided E through multiple exposures to words in natural contexts (Leonard et al., 1982; Marulis and Neuman, 2010) Script-based • Socio-dramatic play routines that engage child interventions  representing familiar event sequences or scripts in (Schank and Abelson, 1977) used to foster social and Interventions for Nonspeaking Children with Profound Hearing Loss Some children are nonspeaking because of severe-to-profound deafness (Brookhouser and Moeller, 1986). For these children, evidence points to two established options for improving communication skills: sign language and/or cochlear implants. Nonspeaking deaf children have been shown to 

TREATMENT AND PERSISTENCE 93 linguistic development; concept is that child’s familiarity with event structure frees up cognitive resources to focus on learning new linguistic targets (Nelson and Gruendel, 1986) Shared/interactive • Adult–child social interactions during storybook book reading  eading tailored to promote a variety of linguistic goals r for child (Bradshaw et al., 1998; Whitehurst et al., 1994) Recast •  aregiver/therapist repeats what child says in C developmentally more advanced form to promote grammatical development (Cleave et al., 2015; Proctor-Williams et al., 2001) Learning Context Clinician support • Emphasis on naturalistic and developmentally for caregiver  appropriate language stimulation throughout daily routines, with a goal of frequent language exposure and frequent opportunities for child to understand and use language Child-centered •  mphasis on maintaining communication interactions E and embedding teaching in natural, playful communication exchanges Hybrid •  ombines home-based and clinician-delivered C interventions Parameters of Service Delivery Dose of treatment •  ocuses on parent/caregiver implementation in F natural daily routines to promote high dosage and generalization Agent of change •  arent/caregiver supported in home setting by P clinician; clinician may provide child-focused intervention with parent training component Treatment setting •  ypically focuses on natural environments (home, T daycare), but may include clinic or early intervention setting be quite adept at acquiring sign language, which provides a rich means of communicating with members of the deaf community and others fluent in that form of communication (Newport and Meier, 1985). In recent years, many of these children have been provided with cochlear implants, which have been shown for some to provide very good speech and language out- comes (Niparko et al., 2010; Tomblin et al., 1999). 

94 SPEECH AND LANGUAGE DISORDERS IN CHILDREN Efficacy of Early Interventions Several meta-analyses in the early childhood special education literature demonstrate the impact of family-centered practices on caregiver abilities. One meta-analysis integrated 52 studies to estimate effect sizes in relation to specific family-centered practices (Dunst et al., 2008). It examined the relationships between family-centered help giving and six categories of child and family outcomes (participant satisfaction, self-efficacy, program helpfulness, child functioning, parent–family functioning, and parenting behaviors). The relationships were significant in all six analyses, with aver- age effect sizes ranging from 0.65 to 0.15 across the six outcomes. Overall, results suggest that family-centered practices have either direct effects on family and child functioning, indirect effects mediated through self-efficacy, or both. A more recent meta-analysis suggests that family-centered practices directly influence parental self-efficacy, and that indirect effects of these practices on parent–child interaction and child development are mediated by caregiver self-efficacy (Trivette et al., 2010). The authors reviewed eight studies including 910 infants, toddlers, and preschoolers with and without developmental delays. Results, which were statistically significant, showed that family-centered help-giving practices and family-systems interventions directly influenced parental self-efficacy and well-being and that there were indirect effects on parent–child interaction and child development, medi- ated by caregiver self-efficacy and parental well-being. Another meta-analysis focuses on 18 studies evaluating the effects of parent-implemented interventions for toddlers and preschoolers with language impairments (Roberts and Kaiser, 2011). This analysis shows that parent-implemented language interventions have a positive impact on children’s receptive and expressive language outcomes relative to a control group. Increasing parent–child turn taking in interactions and improving responsiveness to child communication also are associated with positive outcomes in child language. The effect sizes are statistically significant for receptive language and for expressive grammar. The authors note that the effect sizes for six of the seven language constructs measured are positive and significant. Increasing parent–child turn taking in interactions and improving responsiveness to child communication also are associated with positive outcomes in child language. Law and colleagues (2004) found a significant effect of expressive language intervention compared with no therapy. They also found that speech-language interventions administered to children by speech-language pathologists and interventions administered by parents trained by speech-language pathologists were comparable in effectiveness, suggesting that caregivers can become effective agents of change. 

TREATMENT AND PERSISTENCE 95 Because most of these studies involved parents of relatively high so- cioeconomic status, more research is needed to understand how these approaches are working or may need to be adapted with caregivers in circumstances of low income. Preschool Intervention The preschool period marks a time of transition for children. During this period, children begin to spend more time outside the home and in play-based settings with peers. By 3 years of age, many preschoolers can sit and attend for at least short intervals, and by the end of the preschool period, the typically developing child is expected to be capable of partici- pating in group activities and attending to and following the instructions of an adult (Paul and Norbury, 2012). For the preschooler with developmen- tal disorders, the preschool years also mark a time when clinical services are likely to move out of the home and into centers and clinics. However, parent-based programs are common during these years. The following subsections summarize the treatment modalities that make up the typical standards of care for the preschool child with speech and/or language dis- orders and the evidence for their efficacy. Treatment for Preschool-Age Children with Severe Language Disorders Children with severe language disorders are likely to engage with others to accomplish a variety of communication acts, such as talking about things around them, asking questions, and expressing preferences (e.g., by saying “no”). Their language is likely to be characteristic of a younger child, with limited vocabulary and simple or immature sentences. Importantly, children with severe language disorders also are likely to understand things said to them at this lower level. If this gap in achievement persists into the early school years, these children are likely to enter school with language skills similar to those of children who are 3-4 years old. For these children, the goal of language treatment is to close this gap to the extent possible. To accomplish this goal, therapists need to promote growth in the child’s im- plicit language knowledge base across a range of communication skills. The treatment programs for these preschool-age children (ages 3-5) are diverse and often tailored to the particular needs of the child, based on the factors described earlier in this chapter. The factors that influence language treat- ment programs for preschool children with language disorders fall into four general areas: (1) treatment goals, (2) mode of teaching, (3) learning con- text, and (4) parameters of service delivery. These factors are summarized in Box 3-3 and described in greater detail in the subsections that follow. 

96 SPEECH AND LANGUAGE DISORDERS IN CHILDREN BOX 3-3 Selected Examples of Child-Focused Elements of Language Treatment Programs for Preschool-Age Children Treatment Goals Vocabulary •  ords expressing cognitive states (think, know) W (Rescorla et al., 2000) • Common verbs (Rescorla et al., 2000) • Time, place, and quantity terms (Owens, 2013) Grammar •  eneral principle: target emerging grammatical forms G (Fey et al., 2003) •  uxiliary verbs (“am,” “will,” etc.) (Paul and Norbury, A 2012) • Tense (Rice et al., 2005) •  omplex sentence forms, such as use of relative C clauses (Schuele and Tolbert, 2001) •  resentation of variable lexical items along with the P targeted grammatical structure to promote learning (Plante et al., 2014) Pragmatics •  ontinuation of on-topic conversation (Paul and C Norbury, 2012) •  sking questions that consider the listener’s perspec- A tive (Marton et al., 2005) •  se of verbal skills for conflict resolution (Marton et U al., 2005) Preliteracy •  wareness of the sound composition of words (pho- A nological awareness) (Justice and Ezell, 2000) • Concepts of print (Justice and Kaderavek, 2004) • Alphabetic knowledge (Lovelace and Stewart, 2007) •  nowledge of structures of stories (van Kleeck et al., K 2006) Mode of Teaching Modeling •  rovide frequent examples of learning targets P (Hemmeter and Kaiser, 1994; Leonard et al., 2004; Vasilyeva et al., 2006; Weismer and Murray-Branch, 1989) Treatment goals  Several principles govern the selection of treatment goals. First, the goals are based on evidence of aspects of communication that are known to be vulnerable in children with language disorders. Second, the goals are selected to enhance the child’s ability to participate in social interactions and develop precursor skills for school entry. Third, although treatment goals for children with severe language disorders may be itemized 

TREATMENT AND PERSISTENCE 97 Comprehension •  sk for verbal or nonverbal responses based on A word, sentence, or story meaning (Byrne-Saricks, 1987) Extensions •  ollow child’s utterance with appropriate content F that continues the conversation (Barnes et al., 1983; Cazden, 1965) Expansions •  linician repeats what child says in a developmen- C tally advanced form (Cleave et al., 2015; Proctor- Williams et al., 2001) Recast •  linician repeats what child says in a developmen- C tally advanced form (Cleave et al., 2015; Proctor- Williams et al., 2001) Imitation •  hild is asked to imitate an utterance (Camarata et C al., 1994; Connell, 1987; Connell and Stone, 1992) Learning Context Clinician-directed •  mphasis on high rates of stimulation and child re- E sponses, where clinician elicits language responses with little emphasis on true communication Child-centered •  mphasis on maintaining communication interac- E tions and embedding teaching in the communication exchanges Hybrid •  ombines control of the content and form of the talk C by the clinician with a semi-natural communication exchange Parameters of Service Delivery Dose of treatment •  umber of days per week and duration of sessions N (Law and Conti-Ramsden, 2000; Schooling et al., 2010) Agent of change •  linician versus parent (Fey et al., 1993, 1997) C Mode of participation • Individual versus group (Boyle et al., 2007) Treatment setting • Center/clinic versus home (Schooling et al., 2010) separately, they need to span comprehension, vocabulary, grammar, social communication/pragmatics, and preliteracy, and the treatment is likely to address several of these goals at once (Paul and Norbury, 2012). Finally, specific treatment goals will be based on the child’s developmental readi- ness for learning. For instance, Fey and colleagues (2003) suggest target- ing grammatical forms that are used at low frequencies and thus likely 

98 SPEECH AND LANGUAGE DISORDERS IN CHILDREN emerging in the child’s system. Readiness also can be indicated by evidence that the child is able to use a language form or function when supported by adults (Schneider and Watkins, 1996). Mode of teaching  Two features are common to all of the teaching modes for preschool-age children with severe language disorders. First, an effort is made to increase the amount of language experience provided to the child. Learning theories in psychology often acknowledge that more tri- als in a learning task will result in better learning, and this principle also has been found to apply to language development (Hart and Risley, 1995; Huttenlocher et al., 1991; Matthews et al., 2005; Moerk, 1983). Second, an effort is made to enhance the saliency or prominence of the language target being taught to the child by increasing emphasis on or control over the placement of the target in the utterance (Dalal and Loeb, 2005; Weismer, 1997). One instructional method, referred to as “modeling,” draws on the social learning theory that emphasizes observational learning (Bandura, 1971). With this method, the child is provided an elevated number of exem- plars of a language form. In some cases, this is done in the context of high- density exposures during focused treatment sessions, while in others, it is embedded in natural conversational interactions. In both kinds of settings, modeling has been found to result in gains in the targeted language forms (Leonard et al., 2004; Nye et al., 1987; Vasilyeva et al., 2006; Weismer and Murray-Branch, 1989). As was noted earlier, talk that encompasses semantic extensions, re- casts, and expansions is also often used in preschool programs where clinicians are the agent of change. Several preschool language intervention programs emphasizing responsive language have shown evidence of ef- fectiveness (Bunce, 1991; Dale et al., 1996; Fey et al., 1993; Justice et al., 2008). Common to all of the above teaching modes is the fact that the child is not taught directly to express the target language. In contrast, some treatment programs place a strong emphasis on a direct form of teaching through elicited imitation. In this case, the child is instructed to imitate a word or sentence and given feedback when he or she makes an imitative attempt. A substantial literature has shown that teaching through imitation can result in improved use of the targeted language forms (Camarata et al., 1994; Connell, 1987; Connell and Stone, 1992; Nye et al., 1987). Yet while imitation is clearly effective in teaching specific targeted behaviors, generalization beyond these targets is often limited. In summary, an array of basic patterns of language interactions with children can be used to promote language growth. For example, Law and colleagues (2004, 2008) have performed meta-analyses on the effectiveness 

TREATMENT AND PERSISTENCE 99 of language interventions and concluded that treatment programs are ef- fective for improving vocabulary with a standardized mean difference of 0.89 and mixed evidence for improvement in expressive grammar. A recent meta-analysis on the effect of recasting on improvement in grammar found a mean standardized difference of 0.96 for gains in the targeted grammati- cal form measures and 0.76 for generalization to untreated grammatical forms (Cleave et al., 2015). The evidence is strongest for those methods that include responsive interactions, although directive language engagement, particularly in limited amounts, can also be effective. Most language inter- vention programs combine several of these methods, along with a general emphasis on overall increments in the frequency of language use. Learning context  Most language intervention programs for preschool children use multiple modes of teaching. When these modes are combined, they can result in different types of learning contexts that may be clinician- centered, child-centered, or a mix of the two. The clinician-centered context is one in which the emphasis is on high rates of listening and speaking the targeted language forms within a highly structured drill-and-practice set- ting. The clinician controls what is said and what the child does. Paul and Norbury (2012) note that this approach has been advocated by several clinical investigators on the grounds that children with language disorders need the structure and intensity of this learning context. In contrast with clinician-centered approaches are those that are child-centered, in which the emphasis is on preserving the qualities of natural adult–child interactions, and in particular the pragmatics of conversation. The child is allowed to lead the interaction and thus the content, while the clinician follows. The hybrid approach represents a middle ground. One prominent example is incidental teaching (Hart and Risley, 1975), in which the clinician arranges the play setting to provide for talk about the targets and motivations for talking. Interjected into the play are short intervals of focused teaching that involves more directive language. Many of these services are provided in school-based settings through IDEA. Parameters of service delivery  The ways in which speech and language ser- vices are provided vary along several parameters. One such parameter is the treatment “dose,” including such variables as the duration of the treatment session, the number of sessions, and the spacing of treatment. Although one might expect that more treatment is likely to be more effective, the evidence in this regard is not clear (Schooling et al., 2010). Yoder and colleagues (2012) found that learner characteristics may interact with the influence of treatment dose and that dose effects are complex (Yoder et al., 2012). Another important parameter of service delivery is the agent of change. For preschool children, the principal agent of change may be 

100 SPEECH AND LANGUAGE DISORDERS IN CHILDREN a speech-language clinician, a preschool teacher, or the child’s parents. Comparisons of parents and clinicians as agents have shown that outcomes are largely comparable (Dale et al., 1996; Fey et al., 1993, 1997; Schooling et al., 2010). Outcomes also are comparable whether services are provided in groups or individually, and in centers and clinics or the children’s homes (Schooling et al., 2010). In summary, considerable evidence shows that clinical treatment for language disorders can improve preschool children’s language abilities. However, the learning effects are greatest for those skills that are the target of intervention. The effects of treatment are less pronounced for those skills that reflect a widespread restructuring of the child’s language system. As a result, the preschool child with a language disorder, particularly if the disorder is severe, is likely to continue to have the disorder by the time he or she enters school. Treatment for Nonspeaking Preschool-Age Children At the most extreme end of the continuum of severity of speech and language disorders are children who are nonspeaking. By 3 years of age, the absence of speech is indicative of some form of severe communication impairment (Whitman and Schwartz, 1985). The speech of one-third to one-half of children with cerebral palsy is so limited that it is not functionally intelligible (Andersen et al., 2010; Himmelmann et al., 2013). Another group of children who fail to develop spoken communication are those with severe intellectual disability and/or autism. By 14 months of age, for example, most infants are able to draw the caregiver’s attention to something by pointing and naming. This basic communication function is limited or absent in some children with severe intellectual disability or autism spectrum disorder. Provision of a basic functional communication system has been shown to reduce aggressive and self-injurious behavior in these children (Kurtz et al., 2003). Such systems—termed alternative and augmentative communication systems—can be organized into two groups: those that depend on alterna- tive body systems, such as gestures or facial expressions (unaided commu- nication systems), and those that require some tool or equipment (aided systems) (Romski and Sevcik, 2005), ranging from a set of pictures or paper and pencil to computer-based speech-generating systems. For young children who are not literate, the most common options are those that do not require or use print. If such a child has good motor skills, an unaided system involving gesture or a picture-based system may be employed. A re- view of all of these systems is beyond the scope of this study, but given the focus of this report on young children with severe speech and language dis- orders, two systems used commonly with such children are described below. One of the oldest alternative and augmentative communication systems 

TREATMENT AND PERSISTENCE 101 entails the use of a set of pictures that are arranged on a board or placed on pages in a book (Beukelman and Mirenda, 2005). The pictures often represent basic messages that the child needs or wishes to express. For children with very limited motor abilities, the communication board can be placed on a tray attached to the child’s wheelchair. As the child progresses in the use of the device, it is usually necessary to alter its content to include new messages. Furthermore, as the child’s capabilities with language, print, and mobility change, other alternative and augmentative communication systems may be appropriate. For some nonspeaking children, the absence of spoken communication is due to their lack of understanding of communication functions such as informing a listener about basic needs. Such children need to be introduced to rudimentary communication activities in the hope of not only improving their functional communication skills but also enabling their overall further progress. A common treatment program for this purpose is the picture ex- change communication system (Bondy and Frost, 2001), in which the child is provided with pictures of desired objects and taught to use the pictures to request the objects from teachers or caregivers. Several studies have pro- vided evidence that this treatment increases the number of communicative requests, although evidence that these skills generalize to other communica- tion partners, to other communication functions, or to speech is limited at present (Flippin et al., 2010; Preston and Carter, 2009). Preschool children who are nonspeaking because of poor language abil- ity are likely to have lifelong needs for support, particularly if their deficits reflect severe receptive language disorders and/or other neurodevelopmental disorders. If such children develop any spoken communication skills, those skills may be quite limited. In contrast, if the basis of the communication problem is largely a limitation in speech production, and receptive language abilities are relatively unaffected, computer-based electronic communica- tion systems are likely to be effective, and these children have a good chance of entering into regular education and mainstream society. It is important to emphasize that for many children with severe deficits, the use of alternative and augmentative communication systems may not result in levels of communication found in typically developing children. However, if such a system can increase the child’s ability to communicate five or six messages rather than one or two, the resulting gains for com- municating with parents, teachers, and others may be substantial, and may prevent or resolve aggressive and self-injurious behaviors. Because of the heterogeneity in the etiology of those disorders that necessitate the use of such systems, as well as in the cognitive ability and speech and language level of affected children, much of the research on these interventions has a single-case (single-subject) design (Schlosser and Sigafoos, 2006). This literature indicates that children receiving these interventions improve in 

102 SPEECH AND LANGUAGE DISORDERS IN CHILDREN communication function, but with rare exceptions, they will not develop typical speaking ability and will continue to require alternative and aug- mentative systems as a primary means of communication. Treatment for School-Age Children with Language Disorders As noted earlier, language demands increase substantially as children move from the home to the school setting. Throughout the formal educa- tional process, learning occurs through language and communication. In the classroom, the content of language children hear, and later read, is often new. Classroom language also is “decontextualized”; that is, it refers to events occurring in other times and places (Snow, 1991). Moreover, much of language in the classroom is no longer tailored or even directed to an individual child. In fact, in the primary grades, the majority of children in a classroom may not understand many of the important verbal concepts they encounter (Boehm, 1991). Thus, even children with mild language disorders enter school at a high risk for academic difficulty. Children with severe language disorders have a particularly high risk of learning problems during the elementary years. As discussed in Chapter 2, children with severe and profound language disorders fall more than two standard deviations below the mean for their age group. Thus, a 6-year-old child may have language skills comparable to those of children 2 or more years younger. As a result, a large gap exists between the child’s abilities and the array of language skills required to perform in school. As previously noted, speech and language treatments are not likely to resolve children’s language difficulties completely, nor will they fully protect children from difficulties with school performance. Researchers have recommended a curriculum-based model of treatment for school-age children with language disorders (ASHA, 1999; Simon, 1987; Wallach, 2008). In this model, treatment goals are aligned with the school curriculum, and learning priorities involve skills linked directly to reading, writing, and mathematics. IDEA also plays a role in this curriculum focus by emphasizing that school-based speech and language services should fo- cus on those skills that affect the child’s educational performance. The past two decades have seen an increased emphasis on incorporating speech and language services into the classroom whenever possible instead of remov- ing children from their classrooms for treatment. Evidence concerning the relative effectiveness of classroom-based and pull-out services for children with language impairments is mixed (McGinty and Justice, 2006). Curriculum-based treatment of speech and language disorders in school-age children emphasizes two related areas: (1) metalinguistics and (2) the language bases of reading and writing. 

TREATMENT AND PERSISTENCE 103 Metalinguistics Reading and spelling require that a child think consciously about the sound composition of words and the meaning of words and whole narra- tives. This conscious knowledge of and talk about language itself is called metalinguistics (Bialystok and Ryan, 1985). One of the most common meta- linguistic treatment targets for school-age children with language disorders has been phonological awareness, a form of metalinguistic skill having to do with understanding and awareness of the sound components of words. Learning to read involves the identification of these sound elements and their mapping onto letters and sequences of letters. A number of system- atic training programs are available for improving children’s phonologi- cal awareness (Adams et al., 1998; Blachman et al., 2000). In 2002, the National Reading Panel, commissioned by the U.S. Congress, identified 52 studies evaluating the effectiveness of phonological awareness training in improving reading and spelling (Ehri et al., 2001), concluding that its ef- fect was moderate. A more recent literature review by Snowling and Hulme (2011) yielded similar findings. Language Bases of Reading and Writing Several decades of research on reading and writing has led to an un- derstanding that these abilities are highly linked to spoken language abili- ties (Carroll and Snowling, 2004; Catts and Kamhi, 2005). A prominent model of reading comprehension by Hoover and Gough (1990) identifies two subcomponents that contribute to successful reading comprehension: word recognition and language comprehension. Oral language skills play an important role in each of these subprocesses, as shown in Figure 3-2. This figure, from Scarborough (2001), shows that children’s word recognition entails phonological awareness, which is a common target of intervention for children with language disorders. In addition to being foundational for word reading, phonological awareness is important to spelling (Caravolas et al., 2001). Understanding what is read also involves much of the same language knowledge (vocabulary, grammar, sentence meanings, understand- ing of story structure, and verbal reasoning such as inferencing) as that involved in understanding what has been spoken. This knowledge is a focal point of school-based language intervention as well. Many of the methods used to promote grammatical skills in school-age children are the same as those described in the section on preschool language interventions, although the goals for grammatical development are more likely to involve use and, in particular, comprehension of complex sentences, such as those with relative clauses. Mezynski (1983) argues for a strong correlation between vocabulary 

104 SPEECH AND LANGUAGE DISORDERS IN CHILDREN FIGURE 3-2  A depiction of the bases of reading development. SOURCE: Used with permission by Guilford Press from the Handbook of Early Literacy, Figure 8.1, Scarborough’s Rope, 2003. and reading comprehension. Thus, a treatment program aimed at enhancing vocabulary could result in improvement in reading. More recently, Elleman and colleagues (2009) performed a meta-analysis of the literature on the effects of vocabulary intervention on reading comprehension. They found that children improved their reading comprehension only on measures that included the vocabulary they had been taught directly; their overall reading comprehension did not improve. Other school-based treatment programs focus on the structure and content of stories and expository text (Nippold et al., 2008; Roth et al., 1996), inference making, and metalinguistic knowledge about participation in classroom communication. In general, considerable evidence indicates that such language interventions can result in improvements in the targeted abilities; it is less likely that these treatment effects generalize broadly to effect widespread gains in academic function. Treatment for Speech Sound Disorders As with language disorders, the severity of speech disorders can range from relatively mild to quite severe, up to and including a complete inability to speak. Broadly, intervention for speech disorders can be completed at 

TREATMENT AND PERSISTENCE 105 two levels. Mild to moderate speech disorders (e.g., speaking with a lisp; deleting or distorting the final sounds in words; deleting sounds and conso- nant clusters; or substituting one sound for another, such as “w” for “r”) often are treated with a focus on speech production accuracy for individual sounds (phonemes) (Bernthal et al., 2012). In more severe speech disorders, the focus of intervention may be on improving global speech intelligibil- ity, wherein whole word production rather than individual phonemes is targeted (see Camarata, 2010; Camarata et al., 2006; Levy et al., 2012; McLeod, 2006). When overall speech intelligibility is extremely limited, intervention includes augmentative and alternative communication prosthe- ses, discussed earlier (see Costantino and Bonati, 2014). Generally, primary approaches to behavioral treatment of speech disorders, regardless of level or theoretical underpinnings, include practice moving and coordinating movements of oral structures such as the lips, tongue, and soft palate to improve speech production (Williams et al., 2010). Within the broad rubric of improving speech accuracy, there are a number of approaches, including articulation drill, motor learning, and phonological/lexical interventions. Examples of these approaches are briefly described below. Articulation Drill and Motor Learning Articulation drill approaches focused on motor placement and produc- tion of individual speech sounds (phonemes) often are a primary focus of intervention for speech disorders (McLeod and Bleile, 2004). In essence, a child is taught directly how to move and coordinate the articulatory mecha- nism for producing individual speech sounds (phonemes). For example, a child with a mild speech disorder who says the word “rabbit” as “wabbit” is incorrectly pronouncing the phoneme “r” as a “w.” Intervention in this case would include direct instruction, motor practice, and drill on how to produce an “r” sound correctly. These drills often are completed on indi- vidual sounds in isolation as a preliminary step. After the child has learned to produce the phoneme correctly in isolation, syllabic productions are introduced (e.g., consonant-vowel syllables). Practice is then initiated until the target phoneme is produced correctly in this context as well. After the child has mastered production at the syllable level, word-level productions are initiated, with a transition to phrases and conversational speech to fol- low. This approach has long been a standard method in the field (Nemoy and Davis, 1954; Swift, 1918) and remains a core feature of intervention for speech disorders in children (Maas et al., 2014). One key component of articulation drill is repeated motor practice of the tongue movements and coordination of the other articulators, such as lips and jaw, required for accurate pronunciation. Maas and colleagues 

106 SPEECH AND LANGUAGE DISORDERS IN CHILDREN (2014) review motor learning approaches as applied to speech disorders in children. Although treatment goals often focus on individual speech sounds (phonemes), the authors note that motor practice principles can include syllables, words, and even phrases: “The possible types of targets are numerous and diverse, and include isolated speech movements, speech sounds, syllables, phonetically modified words, real words, nonsense words, and phrases/sentences” (p. 199). In addition to these targets, the authors observe that motor learning can also be applied to intonation and stress patterns needed for accurate speech production (see also Shriberg et al., 1997). Other variations on articulation drill focus on phonemes but introduce specific targets with the goal of generating broader systems change in speech production. For example, Gierut (1990) argues that in maximal contrast articulation drill, speech intervention will be more efficient if selected pho- nemic contrasts differ in terms of place of articulation in the mouth (e.g., lips, alveolar ridge, soft palate, larynx), voicing (voiced as in “b” versus voiceless as in “p”), and manner (vowel-like, frication, and so on). Gierut’s model predicts that training in very different speech sounds (e.g., “p” ver- sus “r”) will yield incidental learning of speech sounds with some of the features contained in the contrast (such as voicing and intermediate place- ment). Williams (2000) also hypothesizes that generalization will take place when training addresses contrasting speech targets, but that the generaliza- tion will be narrower than that proposed in maximal contrast treatment. In a similar vein, some articulation drill intervention approaches focus on patterns of speech sound learning based on “phonological processes,” which are patterns of speech sound production rooted in linguistic feature classifications (e.g., Chomsky and Halle, 1968). In this model, the focus of intervention is on highlighting specific linguistic features that account for systematic errors in disordered speech. For example, it is not uncommon for children with speech disorders to produce the sounds “f,” “s,” and “th” as “p,” “t,” and “t,” respectively (saying pea for fee, tee for see, and bat for bath). These errors indicate that sounds that should be produced with a turbulent airflow (fricatives such as “f,” “s,” and “th”) are instead being produced with complete occlusion of the oral cavity and an abrupt release (stops such as “p” and “t”). In phonological process intervention approaches, the substitution of stop consonants for fricative consonants is called “stopping” or “stopping of fricatives,” so that intervention is de- signed to highlight correct production of entire sound classes, such as frica- tives, when these are produced incorrectly by substituting speech sounds from another class (see Hodson and Paden, 1981; Ingram, 1981; Shriberg and Kwiatkowski, 1980). Interventions based on phonological process analysis continue to be included in current intervention studies (e.g., Dodd, 2013). 

TREATMENT AND PERSISTENCE 107 Phonological/Lexical Approaches Although articulation drill can be applied to words or even phrases, these levels are often generalization targets after motor planning and/ or articulation practice on individual speech sounds has been completed (see Camarata, 1993). A different approach to treating speech disorders is rooted in considering speech sounds within the context of word pro- ductions (see Storkel, 2004). These interventions are designed to improve word-level production rather than starting at the motor learning or indi- vidual phoneme level. Some approaches focused on lexical-phonological learning do not include motor practice or articulation drill. For example, Camarata (1993) found that responsive-interaction intervention based on transactional learning was associated with improved speech production. Similarly, Yoder and colleagues (2005) found that “broad target recasts” improved speech production in children with comorbid speech and lan- guage disorders. In addition, Crosbie and colleagues (2005) found that word-level speech production improved speech disorders in children. These latter studies show that both speech accuracy and speech intelligibility can be improved using lexical-transactional intervention. Efficacy of Treatment for Speech Sound Disorders A number of studies have found treatment to be associated with signifi- cant gains in speech accuracy and intelligibility (Almost and Rosenbaum, 1998; Baker and McCleod, 2011). However, there have been few long- term follow-up studies, and very few studies have been focused on children with severe speech disorders (Baker and McCleod, 2011). Similarly, in a review of the literature on speech intervention in mild to moderate speech disorders, Bernthal and colleagues (2012) conclude that “when comparing groups receiving intervention to those receiving no treatment, the interven- tion group consistently perform better than the no treatment groups on outcome assessment measures. Thus, it would appear that intervention for speech sound disorders does make a difference; however, additional infor- mation is needed regarding the effectiveness of specific treatment methods” (p. 270). As noted, the literature on severe speech disorders, such as dysarthria and childhood apraxia of speech, is highly limited (Morgan and Vogel, 2008). Studies focus on populations such as children with Down syndrome and cerebral palsy as a means of evaluating treatment, and many of these studies are single-subject designs that provide evidence of individual short- term gains in speech intelligibility (as in Camarata et al., 2006). In general, randomized clinical trials that include children with severe speech disorders have been lacking. This is also the case for those children whose speech is 

108 SPEECH AND LANGUAGE DISORDERS IN CHILDREN so severely unintelligible that computerized speech devices are required. A recent meta-analysis of interventions using such devices (Gevarter et al., 2013) found evidence for improvement in specific skills targeted by the treatment and improvement in the use of the devices, but it is difficult to determine whether such interventions result in long-term improvement in speech intelligibility. In summary, as with language disorders, a substantial literature indi- cates that short-term improvements are observed following intervention for speech disorders. A majority of these studies focus on the mild-to-moderate range of severity. Evidence with regard to severe speech disorders is much more limited, and a great deal of this evidence is focused on short-term proximal gains demonstrated using single-subject designs. Treatment for Stuttering A wide range of treatments have been developed for stuttering over the past century. These include psychological-psychodynamic approaches, operant conditioning-behavioral approaches, and technology applications such as delayed auditory feedback devices. In addition, a limited number of pharmacological treatments have been studied, yielding some evidence that medication can be effective in improving symptomology. Broadly, the treatment literature indicates that individual symptoms of stuttering, such as repetitions, intonation patterns, and timing disruptions, can be improved with a variety of treatments. However, Nye and colleagues (2013) conducted a meta-analysis of the stuttering treatment literature and found limited evidence that therapy improves stuttering symptomology. The literature also indicates that recovery rates are higher in preschool than in school-age children, but longitudinal randomized trials comparing treatment with untreated recovery are needed. Stuttering in children whose dysfluencies persist into school age and into early adolescence is most re- sistant to treatment (Guitar, 2013). PERSISTENCE OF PEDIATRIC SPEECH AND LANGUAGE DISORDERS IN CHILDREN Over the past three decades, several longitudinal studies have examined the persistence of early speech and language delays during later preschool years and well into the school years. Persistence of Early Speech and Language Delays The question of persistence requires that the age of onset of speech and language disorders be considered. As discussed in Chapter 2, these disorders 

TREATMENT AND PERSISTENCE 109 do not have a clear age of onset; rather, they emerge as a child begins to engage in spoken communication at around 2 years of age. This pattern of emergence results in a period of ambiguity with respect to when the diag- nosis of a persistent disorder can be made. Early signs of delayed speech and language development become evident at approximately 2 years of age, when most children can understand and say a number of words. Several studies in the early 1990s analyzed parent reports of children’s speech and language around this age. Parents were asked whether children who had very limited expressive language at around 2 years of age could be consid- ered as having a persistent condition that warranted clinical intervention. Children in these studies who had very limited expressive language were categorized as “late talkers” (Paul, 1993; Rescorla and Schwartz, 1990; Thal, 1991; Weismer et al., 1994). Usually, to be considered a late talker, the child had to be free of other developmental or sensory disorders; thus, being a late talker was viewed as a possible early manifestation of primary language disorder. Even though the diagnosis often emphasized expressive vocabulary, many of these children also were found to have poor speech sound production, reduced language comprehension, limited use of word combinations, and limited use of nonverbal gestures and symbolic play (Desmarais et al., 2008). The investigators in these studies followed these late talkers longitudinally into the preschool years and in some cases into adolescence. The language measures obtained during the preschool years for children who were late talkers as toddlers showed that, as a group, they continued to perform below their age mates on many language measures; however, their mean scores were also at the low end of the normal range (Dale and Hayiou-Thomas, 2013). Thus, there was evidence of improvement among at least a subgroup of these children. It should be noted that, although late-talking children may also display speech disorders, longitudinal studies of this group have not systematically assessed speech skills during follow- up. Children who are late talkers are more likely to continue to manifest language development at the lower end of the normal range, often lagging behind their same-age peers (Dollaghan, 2013; Thal et al., 2013). An important feature of many of these studies is that the participants often were from socioeconomically advantaged homes. Paul and Weismer (2013) note that late talking can be viewed as one risk factor that, when combined with poverty, increases the risk that a child may have persistent problems. Many of the studies of late talkers also have identified other risk factors for persistence, such as poor language comprehension, limited engagement in communication, more severe language delay, and a family history of language and reading impairment (see also the discussion of risk factors in Chapter 2). Because most of the research on the persistence of late talking has focused on children with few other risk factors, further research 

110 SPEECH AND LANGUAGE DISORDERS IN CHILDREN is needed to determine the extent to which late talking in combination with other risk factors is predictive of the persistence of poor language skills. Persistence of Language Disorders During the School Years Although research on the persistence of early speech and language delay suggests that many children who are late to begin talking as toddlers show gains in language that eventually place them at the lower end of the normal range, a number of children who are late talkers as toddlers have persistent language disorders through the preschool years. Joining these children are those with normal language at 2 years of age who subsequently show declines in language skills (Ukoumunne et al., 2011) and those who also display speech disorders. Several studies have assessed the long-term persistence of speech and language disorders among children who are at the end of the preschool years. Beitchman and colleagues (Johnson et al., 1999) followed a large sample of children with and without speech and language impairment at 5 years of age into adolescence and found that 71.4 percent had persisting language problems, compared with a rate of 5.5 percent in control chil- dren who had normal language in kindergarten. They also found that 10.9 percent of the speech-impaired group had persistent speech disorders at follow-up. These findings were similar to the statistically significant findings of Bishop and colleagues over a similar follow-up period: 90 percent of chil- dren with language impairment at 5 years of age continued to present with language impairment at 15 years of age (Stothard et al., 1998). However, an earlier study by Stark and Tallal (1988) found that only 21 percent of the 6-year-olds in their cohort continued to have specific language impair- ment by 10 years of age. A 28-year follow-up of early-school-age children with and without speech disorders (Felsenfeld et al., 1992) showed that performance on measures of both speech and expressive and receptive language in the speech-impaired group in adulthood was poorer than that of controls. Because the participants in this sample were initially identified using a speech measure only, their language ability at intake is unknown. Subsequently, Tomblin and colleagues (2003) found that 51 percent of 6-year-old children who met criteria for language disorder continued to have impaired language 2 years later. A similar statistically significant rate of persistence (52 percent) was found 4 years later. Additional analyses of the language growth trajectories of these children with language impair- ment showed that they had very stable patterns of growth, and their lan- guage status at age 16 was highly predicted by their language status at age 6 (Tomblin et al., 2014a). Thus, although these children showed growth in language over the span of 10 years, there was little evidence of any recovery or resolution of their language impairment. In another recent examination 

TREATMENT AND PERSISTENCE 111 of persistence of language impairment, Rice and Hoffman (2015) followed 519 children from age 2 to age 22 with regard to their vocabulary devel- opment. The authors found that children with language impairment had poorer rates of vocabulary growth than the controls throughout childhood. They found “minimal[ly], but statistically significant” male–female differ- ences in this pattern of growth (Rice and Hoffman, 2015, p. 356). The results of these longitudinal studies strongly support the earlier conclusion drawn by Stothard and colleagues (1998) that “if a child’s language dif- ficulties are still present at age 5-6 prognosis is likely to be poor and the child will be at high risk of language, literacy, and educational difficulties throughout childhood and adolescence” (p. 417). This conclusion directly parallels what is seen in speech disorder. In a follow-up study of children with speech disorders, Shriberg and Kwiatkowski (1988) note that “find- ings indicate that a high percentage of children continued to have speech and language and other special educational needs as they neared middle school and beyond. Many children eventually required special class place- ments” (p. 144). Persistence of Stuttering (Fluency Disorders) As with mild to moderate speech disorders and mild to moderate lan- guage disorders, relatively minor dysfluencies of preschool children tend to resolve by the time children enter school or shortly thereafter. In a lon- gitudinal study, for example, Kloth and colleagues (2000) found that 7 of 93 preschool children identified as at high risk for stuttering persisted as stutterers 6 years later. In contrast, in more severe cases and cases in which the onset of stuttering occurs later (i.e., after the child enters school), the disorder tends to persist and often is lifelong, although some improvement can be seen through the teenage years (Howell and Davis, 2011; Yairi and Ambrose, 1999). Summary In summary, children who present with poor speech and language ability are likely to show long-term patterns of poor speech and language development throughout childhood. If deficits occur in early childhood and are not severe, the child’s language outcomes may progress into the broad range of typical development by the end of the preschool years. However, deficits are likely to persist in young children with severe deficits and in those with other risk factors, such as other developmental disorders and challenging family environments. High rates of persistence become much more likely for children whose language deficits remain at the end of the 

112 SPEECH AND LANGUAGE DISORDERS IN CHILDREN preschool years. Thus, the determination of a persisting language disorder in early childhood is at best provisional. FINDINGS AND CONCLUSIONS This chapter has reviewed the literature on current standards of care for speech and language disorders in children, which of these disorders are amenable to treatment and the typical time course required for this treat- ment, and the persistence of these disorders. Based on its review of the best available evidence, the committee reached the following findings and conclusions. Findings Treatment 3-1. Few treatments exist that can alter the underlying cause of a speech or language disorder. 3-2. Alternative and augmentative communication treatment can pro- vide nonspeech alternatives to speech that lead to functional gains in communication. 3-3. Speech and language therapy during the preschool years focuses on the promotion of implicit learning of an abstract system of principles and symbols. 3-4. In accordance with policies and practice guidelines, speech-lan- guage intervention often is conducted in the home and/or class- room and incorporates communication needs within the family and the educational curriculum. 3-5. Evidence indicates that speech and language therapy results in gains in the skills and behaviors targeted by the therapy. Persistence 3-6. Toddlers who are late talkers often make developmental gains; however, these gains may be less likely in children whose condi- tion is severe and who have other neurodevelopmental and socio- economic risk factors. 3-7. Children with language disorders at the age of 5 or 6 are likely to have persistent language problems throughout childhood. 

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